Culturally competent care for GLBT people: Recommendations for health care providers
A health care provider's job is to care for the health of her or his patients. This necessarily requires that the provider understand important details about the patient's behaviors, and that the patient invests in the provider with a high degree of trust.
A health provider's role in culturally competent care
In order to gain trust, you will need to create an atmosphere of openness and affirmation with all patients. There are many different components to creating an environment welcoming to GLBT patients, including outreach, office space, intake forms, confidentiality policies, staff training, and the patient interview. Small changes you make in these areas can have a big effect on the comfort felt by your GLBT patients, and this will translate into a more satisfying patient-provider relationship and better health outcomes.
Sometimes providers are unaware of the degree of discrimination a GLBT person may have experienced in the health care setting, and of his or her resulting discomfort in your office. Sometimes this bias may be very obvious and flagrant. More often, however, the discrimination is felt in many small and seemingly subtle ways that add up to the GLBT patient feeling invisible and unsafe. For example, providers commonly ask women what form of birth control they use while performing a gynecological exam. Not only does this assume heterosexuality, it forces the lesbian patient to come out to their provider at an extremely vulnerable moment.
These webpages provide simple and specific recommendations for making your practice more welcoming to your GLBT patients. Remember that cultural competence is a learnable skill. It requires ongoing practice and commitment. Expect to make "mistakes" in good faith, and be willing to grow in your understanding.
Discrimination in healthcare
Unfortunately, gay, lesbian, bisexual and transgendered people have reasonable fears of discrimination when seeking health care:
A 1998 survey of nursing students showed that 8 to 12% (depending on whether the respondent rated gay, lesbian or bisexual) despised lesbian, gay and bisexual people, 5-12% found lesbian, gay and bisexual people disgusting and 40-43% believed that lesbian, gay and bisexual people should keep their sexuality private.
In a 1996 survey of 1,027 New Mexico physicians, 4.3% indicated that they would deny gay and lesbian people acceptance to medical schools and 10.1% believed that gay and lesbian physicians should be discouraged from seeking obstetrics/gynecology training. In the same study, over 20% of the general practitioners, 9.3% of family practice physicians and 4% of pediatricians reported that they would discontinue patient referrals to gay or lesbian surgeons. (The good news is that provider attitudes have improved since a 1986 California study in which 40% of MDs said they were uncomfortable with treating gays and lesbians, 30% opposed admitting gays and lesbians to medical schools, and 40% would not refer clients to gay or lesbian colleagues.)
A 1991 Midwest study of nursing students' attitudes toward lesbians reported that 50% of nursing students felt that lesbianism was "unacceptable," 28% believed that "lesbians transmit AIDS," and 15% believed that lesbianism was "illegal."
In survey published in 1988, 84% of lesbians surveyed had experienced a general reluctance to seek health care, finding it nonempathic. This study revealed that 96% of lesbians "anticipated situations in which it could be harmful to them if their health care provider knew they were lesbian."
A 1985 survey published in the American Journal of Public Health looked at health care professionals' reactions after patients stated that they were lesbian. It revealed that 89% of the professionals had negative reactions: 12% were cool to the news, 30% were embarrassed, 25% responded in an inappropriate way, either by offering mental-health referrals or asking voyeuristic questions, and 22% rejected their lesbian clients overtly by leaving the examination room and having their nurses finish taking the health histories.
A 1981 study showed that when a patient was known to be gay, physicians tended to interpret the presenting problem in sexual terms. When the patient was not identified as homosexual, other diagnoses were more often considered.
Basic tips for culturally competent care
Approximately 5 to 10% of your patient population may be lesbian, gay and bisexual and approximately 1 to 10% may be transgendered (not all will be transsexual, though). If these numbers sound high to you, it may be that you are not asking the right questions, or that patients are not comfortable disclosing. Begin with self-evaluation and reflection. What expectations and assumptions do you bring to the patient encounter? What values, biases and beliefs?
- Sexual behavior may change over time, and sexual orientation is not synonymous with sexual behavior. For example, a woman may state that she is a lesbian, but engages in occasional sex with men.
- Negative past experiences, provider-patient power dynamics, and societal pressures may make it very difficult for patients to disclose same-sex behavior in a health care setting. Be sensitive to your verbal and your body language to create an atmosphere of care, openness and non-judgment.
- GLBT patients are likely to be especially conscious of protecting their privacy in medical records, and the potential disclosure of their sexual orientation on medical records may be a factor in their willingness to discuss it openly with you. Be explicit with patients about how and whether you will document of sexual orientation in the medical record and obtain the patient's permission before doing so.
- Be familiar with appropriate GLBT community referrals. Referring GLBT patients to health resources in their community is analogous to referring an older client to services targeting elderly people or a person with diabetes to the American Diabetes Association. GLBT organizations in your area will be happy to provide you with brochures to hand out to patients.
- Again, remember that cultural competence is a learnable skill. GLBT patients will notice your attempts to be welcoming and will respond very positively.
Outreach to GLBT clients and patients
This is where creating a welcoming environment begins. Few providers target GLBT people with marketing and outreach, and GLBT people are likely to respond very favorably to advertisements in local GLBT service directories and publications. This is a direct indication that you are interested in welcoming GLBT patients into your practice.
- Place advertisements in GLBT periodicals and local service directories.
- Send speakers to meetings of GLBT organizations to announce your practice.
- Promotional literature about your practice should specifically state that services are provided without discrimination based on sexual orientation or gender identity.
- Design, enforce, and publicize a system for maintaining confidentiality of client records.
Tips for creating a welcoming office culture
- Post a sign in the waiting room that says "We do not discriminate on the basis of age, race, sex, sexual orientation, gender identity, religion, language, or disability." GLBT people notice when sexual orientation and gender identity are included in non-discrimination policies, because they often are not.
- Have an affirmative action policy for hiring "out" GLBT people. This will go a long way towards making GLBT patients more comfortable.
- Waiting room reading materials and bulletin boards should include positive items about the GLBT community and materials of interest to the GLBT community.
- Provide in-depth training for staff members on homophobia and GLBT health concerns. All staff dealing directly with clients should be able to talk comfortably about all forms of sexuality and all gender identities. Have staff practice with each other until they are comfortable.
- Friends and partners of GLBT patients should be given the respect and privileges usually given to a spouse or relative.
- Provide an evaluation form with questions concerning heterosexism/homophobia so GLBT clients can give you feedback.
History and physical intake form
- Patient intake forms should be free of heterosexual assumptions. Include options such as "Living with domestic partner" as well as standard options such as married and single. Instead of "husband/wife" use gender neutral terms such as, "partner."
- Whenever there is a sex or gender question, add a third category for transgendered with space that people can elaborate. Do not list transgendered as an alternate sexual orientation (like lesbian, bisexual, or heterosexual). Gender identity and sexual orientation are distinct.
- Questions about families should allow for alternative families including two parents of the same sex and more than two parents.
- Intake forms need to include an explanation about how confidentiality will be protected and who has access to medical records. Offer the patient the right to refuse to answer a question on the intake form if they are concerned--you can discuss it in your office.
- Click here for a sample intake form for culturally competent care.
Remember that any person who walks into your office could self-identify as gay, lesbian, or bisexual and/or have a history of relationships with members of the same sex. Similarly, they may have been born the other sex than they appear. If a patient has left blanks on the intake form, this may be an indication that they felt uncomfortable being open in writing. You have another, better chance to create trust with the GLBT patient during the initial interview.
- Ensure that questions you ask are open-ended and apply to all patients.
- It is important to take a complete sexual history in a non-judgmental manner. Revisit the sexual history each time you see the patient as practices and partners may change (this is true, of course, for heterosexual/non-transgender patients, too). It is important when discussing sexuality to focus on behavior and not just sexual orientation or identity, as not all people with homosexual behaviors identify as such.
- If a patient seems offended by something you've said, you may simply apologize and offer a brief explanation about why information is necessary to provide the best care possible. Ask what terminology the patient prefers.
- Seek out colleagues who have experience in gay, lesbian, bisexual, and transgender healthcare (many more providers are experienced with GLB health than with transgender health). You may use these colleagues for advice and for referrals.
- Explain how the patient's confidentiality will be protected, and who will have access to the information. Give the patient the option of refusing to answer a question. If the patient's confidentiality cannot be protected, it may be to the patient's disadvantage to provide specific information if it is recorded in the medical chart.
- If a teenager or young person does disclose their lesbian, gay, bisexual, or transgendered identity to you, you must treat this information with great privacy and respect. You may be the first person he or she has told. As sexual minority young people are at increased risk for both suicide and abuse, pay special attention to the mental health of this patient. Ask about the patient's access to support. Isolation from peers and rejection by family are very real risk factors for some sexual minority youth.
- Ask GLBT patients about a personal history of hate crimes/violence. Victims of violence are at increased risk of post-traumatic stress disorder.
- If you are a pediatrician seeing a child with same-sex parents, include both in discussions about the child's health care even if both do not have legal custody. Health care is compromised when any primary caregiver is excluded.
Transgendered people are especially likely to have experienced misunderstanding and bias in a healthcare setting. Most health care providers, like most people in general, do not know any transgendered people nor do they understand the motivations behind transgender identification.
You have an excellent opportunity to create a safe and non-judgmental environment for your transgendered patients, and it will be greatly appreciated. Recognize your personal feelings and biases about transgendered individuals' motivations or mental status. Express your primary interest and concern in your transgendered patient's general well being or specific complaint, as you would any other patient.
- Remember that gender identity (e.g., male, female, and transgendered) is distinct from sexual orientation. Some transgendered people identify as transgendered, some identify as male or female, and others identify as both transgendered and male or female. How a person identifies their gender may also change over time.
- Educate yourself about basic transgender healthcare issues, including hormone doses and their effects and available surgeries.
- Be aware of uncomfortable feelings that transgendered patients may feel about their bodies or life histories and the particularly difficult experiences they may have had in the healthcare environment. Transgendered patients may be particularly sensitive about disrobing for examinations.
- Avoid making assumptions about a patients' sexual orientation, relationships or parental status based on a particular gender identity or expression.
- Recognize that not all natal sexual organs may have been surgically removed in transsexual individuals, and that there may be consequent screening exams which need to be performed. For example, it would be common to conduct prostate exams for the post-operative MTF and breast exams and cervical exams for the post-operative FTM. Respectfully ask the patient which surgeries, if any, he or she has undergone.
- Transgendered individuals receiving hormone therapy should be monitored carefully by knowledgeable providers.
Avoiding assumptions about GLBT patients
Below are some of the most common incorrect assumptions about gay, lesbian, bisexual, and transgendered people. You shouldn't feel surprised or embarrassed if some of these thoughts have occurred to you; that is true for most people. Remember that cultural competence is a learnable skill requiring ongoing practice and commitment, and that small changes will make a big difference to your GLBT patients.
- Avoid the assumption that your patients are heterosexual just because they haven't told you otherwise. It may take time for a GLBT patient to trust you.
- Lesbian, gay, bisexual and transgender people often have children. Make no assumption that a patient with children is heterosexual.
- If a teenager tells you he or she may be gay, lesbian, or bisexual, be open and supportive. Try to avoid the assumption that he or she is going through a phase or is too young to make such a declaration. Teenagers are often aware of their sexual and romantic attractions. Some may indeed be unsure what their orientations are yet, but to assume they cannot know at this age will foreclose their being candid with you.
- Equally, children usually know their gender identity at a very young age. If a child or young person expresses to you that he or she feels like a boy even though he or she is biologically female, or vice versa, be respectful of this information and supportive of the child. You have been trusted with very personal information, don't assume that it is false or that she or he needs to be talked out of it.
- All women need regular Pap tests, including lesbians. There is evidence that women who have only female sex partners contract HPV at significant rates. Many women who identify as lesbian have male sex partners or have had male sex partners in the past.
- Transgender men (female to male transsexuals) need Pap tests, unless they have had a complete hysterectomy. Do not assume that a transgender man has had a hysterectomy; many have not. Be especially sensitive when performing a gynecological examination on a transgender man. This is likely to be an extremely uncomfortable experience for him, both physically and emotionally. It is critical that you continue to use the male pronoun ("he") when performing this procedure.
- Transgender men (female to male transsexuals) need regular breast exams, as all breast tissue has generally not been removed even after chest reconstruction. As stated above, this may be an uncomfortable experience for him, and it is critical that you continue to use the male pronoun ("he") when performing this procedure.
- Transgender women (male to female transsexuals) need prostate exams. This may be uncomfortable, and it is critical that you continue to use the female pronoun ("she") when performing this procedure.
- Remember that sexually active gay or bisexual men may need STD screening from the pharynx and rectum as well as genitals, as per their behavior.
- However, avoid the assumption that a gay man's health issues revolve around sexuality, sexually transmitted diseases, or HIV/AIDS. Consider all possible diagnoses for a set of symptoms as you would with any other patient.
- Avoid the assumption that lesbians are not at risk for sexually transmitted diseases. Many STDs have been found to be readily transmissible between women (trichomoniasis, HPV) and lesbians may have sexual contact with men.
- It is important to screen for domestic violence among GLBT persons as well as heterosexuals.